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UNIVERSITI KEBANGSAAN MALAYSIA

HEALTH DECLARATION AND MEDICAL EXAMINATION FORM FOR STUDENT APPLYING FULL-TIME COURSE FURTHER EDUCATION

PERSONAL DETAILS

Name:

I.C. No:

Date of Birth:

Sex:

Marital Status:

Home Address Contact No. (Hp/H)

Name, relationship and address of next kin: Contact No. (hp/h):

HEALTH DECLARATION (to be completed by student) Have you ever suffered and of the following conditions?

ILLNESS YES NO

Psychiatric illness/(sakit jiwa)

Epilepsy/(sawan)

Migraine/(migraine)

Hysteria (hysteria)

Allergic Rhinitis/(resdung)

Asthma/(lelah)

Tuberculosis (PTB)/(batuk kering)

Hypertension (HPT)/(darah tinggi)

Diabetes Mellitus (DM)/(kencing manis)

Heart Diseases/(penyakit jantung)

Thyroid Diseases/(penyakit tiroid)

Kidner Diseases/(penyakit buah pinggang)

Gastric/(penyaking gastric)

HIV/AIDS

Cancer (Barah)

Venereal Diseases/(penyakit kelamin)

Leukemia/(leukemia)

Hepatitis/(hepatitis)

UKM-SPKP-JP-PK06-BO05 No. Semakan: 00 Tarikh Kuatkuasa: 01/05/2012

MEDICAL EXAMINATION FORM

CONFIDENTIAL PROGRAM: _____________

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Please State/(Sila Nyatakan)

Other illnesses: ___________________________________________________________ Operation/Surgical: ________________________________________________________ Allergic: _________________________________________________________________ Family Medical History: _____________________________________________________ Disability/Handicap: ________________________________________________________ I herby certify that the above information is true and complete, and agree that any misrepresentation or deliberate omissions of a material fact on the form may result in my not being permitted to enter a program, or may result in termination. I hereby grant Human Resource Development Section, Universiti Kebangsaan Malaysia, permission to share information contained in my Medical Examination form. Date: ________________ Signature: _________________

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MEDICAL EXAMINATION (to be completed by certified physician) (Physician must complete all questions and give additional comment where necessary. Kindly note that physician is responsible for the information, suggestions and recommendation regarding the student’s health given in this form).

Student Name:

Date of Birth:

PHYSICAL EXAMINATION

Weight:

Height:

Blood Pressure:

Pulse:

Skin:

Color:

Eye Vision Test (RT)

Eye Vision (LT):

Are there abnormalities of the following systems? If yes, describe fully using additional sheet if necessary.

SN SYSTEMS NORMAL ABNORMAL COMMENT

1 Skin

2 Head

3 Eyes

4 Ears

5 Nose

6 Mouth

7 Neck

8 Chest

9 Breasts

10 Cardiovascular

11 Syncope

12 Chest Pain

13 Heart Murmur

14 Abdomen

15 Genitourinary

16 Extremities

17 Neurologic

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URINE TEST

NAD WBC RBC PROTEIN GLUCOSE

HEPATITIS TEST

POSITIVE NEGATIVE

PREGNANCY TEST

POSITIVE NEGATIVE

Is the student now under treatment for any physical or emotional condition? _______________________________________________________________________ Do your have any recommendations for the health care of this student? _______________________________________________________________________ By history and physical examination, is this student a carrier of any communicable disease? _______________________________________________________________________ Date: _______________ Physician Signature: _____________ Note: In completing this form, particular attention should be paid to following points: (a) X-ray of chest to rule out any tuberculosis or chronic pulmonary disease: Where the film is entirely normal it needs not be forwarded, but if any abnormality

is noted the film should be sent with this report. (b) Kidneys: no evidence of renal lesion should be present.

(c) Eyesight – severe errors of refraction should be not be passed as these should only give trouble during the years of study.

(d) Hearing – deafness should be considered a definite bar Human Resource Development Section Registrar’s Office UKM